Datix Insights

A look back at Patient Safety Congress 2018

As part of a new Datix Insights feature, we're going to be taking a look at the latest industry news to break within the NHS and the wider healthcare industry.

We'll offer our own unique perspective on the news, what it means for the patient safety landscape, potential effects on our customers and recommendations on how to deal with new regulations and guidance.

A look back at Patient Safety Congress 2018

The Patient Safety Congress is an annual forum which has been held since 2008 and attracts 1000+ attendees every year. It is aimed at healthcare professionals who are at the forefront of safety, quality improvement and clinical excellence initiatives.

The Congress aims to transform the UK’s approach to delivering high quality care. It champions patient safety as the organising principle of a healthcare system which is truly efficient, effective and able to offer the best experience to patients and carers.

The biggest names in patient safety regularly speak at the event, alongside patient voices who genuinely sit at the heart of the congress programme.

Datix was championing patient safety as a premium partner at this year’s Patient Safety Congress. The Datix team were on hand to chat and answer questions from attendees and demonstrate how Datix Cloud IQ is pushing the boundaries in quality management and supporting the positive work that was talked about at this year’s Congress.

Datix teamed up with NHS Improvement and delivered a talk on, “Using incident reporting to avoid potential harm in clinical and operational systems.” During the talk we assisted the audience with understanding the factors that underpin and contribute to incidents, how they can analyse data to gain insights needed to underpin and implement improvements and take steps to predict and prevent future harm. NHS Improvement ended the talk with positive examples of how they identify and respond to incidents that are being reported with the support of patients and healthcare staff.

Here we cover some of the information and themes from the various talks that were delivered at this year’s congress.

Just Culture

The opening topic at the Congress was ‘Just Culture’, how we need to move away from blame, move toward a restorative rather than retributive culture and the challenges to achieving this.

The opening speaker, Professor Sidney Dekker (Author of Just Culture: Restoring Trust and Accountability in your Organisation, Griffith University) said ‘no blame does not equal no accountability’. Blame leads to more accountability from everyone and above all, answers to that which has gone wrong.

This talk highlighted three simple questions that must be asked to achieve a restorative culture:

Who is hurt?

What do they need?

Whose obligation is it to meet that need?

At Datix we pride ourselves in helping our customers understand the reasons behind things that go wrong. Our systems gather and record information in a secure environment and using analytical tools we help our customers understand what action can be taken to reduce and monitor risk.

Human Factors

There were a series of talks touching upon the importance of human factors. All too frequently we hear in the media about the pressure healthcare providers are under. In an industry that relies heavily on its staff working within the boundaries of systems to mitigate risk, the rise in demand for services increases the risk of adverse events happening and human factors featuring as significant contributory factors.

A Human Factors Specialist commented on how it is in people’s nature to cut corners to reach the end goal, and the interactions between people and elements within the system lead to designs based on user’s experience. This image, used during the talk demonstrates an everyday occurrence we can all relate to.

With increased pressure comes increased risk for things to happen beyond our customer’s control. Using the Capture, Evaluate and Strategy toolkits our customers can identify, monitor and develop solutions to help minimise risks in connection with the increasing demands on their services.

The timing of the congress coincided with the release of Health Safety Investigation Branch’s (HSIB) recent report, which observed that the national serious incident reporting system does not require inclusion of data regarding human factors. The report states how inclusion of such data would be beneficial for future developments to the system.

Deteriorating Patient and Rapid Response Systems

This year’s congress was held alongside the international conference on Rapid Response Systems (RRS). With the focus on the prevention and response to acute deterioration, RRS has been developed to proactively identify patients at risk of clinical deterioration within hospitals and to deliver reliable, safe and quality treatment to those individuals. The most heard diagnosis in connection with deteriorating patients is sepsis. The cost to healthcare and the impact of sepsis on patients and their family’s lives can be considerable. By using the Datix Cloud IQ Investigations Module we are now able to plot a patient’s clinical observations and see through graphical representations when and how a patient started to deteriorate. Below is an example graphical representation:

With this information stored in Datix Cloud IQ’s secure Cloud hosting service, future analytical toolkits will identify how well staff react when a patient deteriorates and pinpoint any gaps in the care. Identifying themes and trends in this way will ensure our customers focus their resource on the areas with the most common contributory factors. Risk Monitors in the Datix Cloud IQ Enterprise Risk Manager module allows customers to monitor in real-time the risks identified from investigations.

Safety Critical Industries

Professor Alison Leary, Chair of Healthcare & Workforce Modelling, London South Bank University delivered the ‘James Reason Lecture’. In her presentation ‘Hope is not a plan: What can healthcare learn from safety critical industries?’ Professor Leary delivered some profound messages from the Safety Critical Industries she visited in preparation for delivering the lecture, closing the first day of the conference with the message “it’s ok to say it’s not ok”. She found that industries where dissent is encouraged among staff has a real value in creating a just culture. She said that if you need to blow a whistle to be heard, something has gone wrong. With the Datix Anywhere mobile app staff are able to raise incidents quickly and take photographs while on the move, bringing a new source of information and helping healthcare workers to capture all incidents.

Patients

In addition to many professionals in the field of patient safety both as speakers and in the audience, the congress also included patients, relatives and campaigners who all had their own experience of questioning the system, culture and chasing answers to events occurring in connection with care they or their loved ones received. All have the same common goal, to learn from incidents and ensure the same thing that has happened to them or their loved one, does not happen to someone else.

Datix

Datix has been a leader in the field of patient safety for over 30 years, providing organisations with a memory of what works and why. Partnering with Patient Safety Congress this year provided us the opportunity to champion patient safety and stimulate conversation around using the incident as the key to avoid and predict future harm. We’re looking forward to continuing the conversation at next year’s Congress.

Want to visit Datix at Patient Safety Congress next year? Sign up here.

Want to find out more about how Datix Cloud IQ can help you improve your quality improvement processes? Email us.